19 August 2008

You know you're in trouble when you call poison control and the attending toxicologist just laughs and laughs at your consult. I don't mean a little snicker, but a full-throated guffaw, lasting thirty seconds, followed by, "Seriously? You're not shitting me? I've been doing this 25 years and even I've never heard of that one!"

The case was, I must admit, unique.

The patient was a 22-year old man with a known history of schizophrenia, who had been admitted to the hospital for a soft-tissue infection which had subsequently developed into CA-MRSA osteomyelitis, an infection of the bone. This required long-term IV antibiotic therapy, so the patient had a PICC line inserted. I'll give the hospitalist team credit -- they considered the wisdom of sending a mentally ill person home with an indwelling venous catheter, even to the point of having an inpatient psychiatry consult regarding that issue. The big risk is generally that patients might inject heroin or other illicit substances into their line, or that they will not keep it clean and they will develop line sepsis. However, the patient had never been known to abuse drugs, and his delusions seemed well-controlled on his medications, so it was ultimately decided to be safe. They arranged close home health support and frequent checks with his case manager and home he went for six weeks of IV antibiotics.

Somewhere around week four, he quietly began getting more delusional. The thought of having an infection in his bones seemed so dirty, so impure. He spent more and more time dwelling on how filthy and repugnant he was inside. He wanted to cleanse himself, to undergo a purification, a catharsis. The antibiotics clearly weren't working, because he still felt unclean, tainted. So he started casting about, looking for something he could do to quickly eradicate the pollution from his bones. What could he use to get rid of this contamination?

So he consulted Google: what kills germs best? The answer:Yes, bleach. Good old household, undiluted 5.5% sodium hypochlorite. It kills all germs, doesn't it? That'll fix what ails me, he figured, and proceeded to draw up 40cc of bleach into syringes and inject it into his central line.

The home health aide came over shortly to get his daily antibiotics started, but the patient cheerfully and proudly informed her that he wouldn't be needing any more antibiotics, because he had cured himself. I can only imagine her reaction when he told her how.

Thus he came to me.

As I mentioned above, poison control was not exactly helpful to me. He thought it was hysterical, but could give no meaningful guidance. A lit search was more or less fruitless as well. I had a feeling that he would be fine: many suicidal patients try to kill themselves by drinking bleach, but wind up disappointed at what a benign and well-tolerated substance it is. So we worked him up.

We had the hardest getting labs on him. The lab techs reported that when they tried to spin his blood down, they couldn't -- it had just turned to a gelatinous goo in the tubes. The bedside chemistry machine reported more or less normal electrolytes, but the tea-colored urine coming out of his foley catheter looked ominous.

Eventually I was able to calm the toxicologist down enough to rationally discuss the case. We figured that the bleach probably would have been pretty rapidly diluted when injected directly into the central circulation (I still somehow can't believe I'm typing those words), so the likelihood of end-organ injury was probably low. But the portion of the blood that was exposed to the higher concentration bleach probably would hemolyze, spilling hemoglobin into the extravascular space.

So we could think of this as resembling rhabdomyolysis, with elevated myoglobin levels, or, more aptly, like blackwater fever. We hydrated the hell out of him, since hemoglobin is very toxic to the kidneys, monitored his potassium, renal function and blood pressure, and admitted him.

I'm pleased to say that he did fine. Full recovery, and off to a med-psych facility within forty-eight hours.

And now I've got a great case to write up if I ever feel like getting published. (I suspect I'm too lazy.)

This happened once to a dog at a vet hospital where a vet tech friend of mine worked. Someone accidentally hung a bag with 50cc bleach in 1L saline, and infused it IV overnight (the dog weighed about 70 pounds). When they realized their major fuck-up the next morning, they pulled a CBC/chem prof, which came back perfectly, perfectly normal, and the dog was happy as a clam. No one could ever explain that one.

So here is one for you about bleach, I was dealing with a couple of nasty boils. Nothing was working until I put bleach on them. Did'nt hurt much and they healed up within a couple of days rather than a couple of weeks like they usually do.

Do you know if the bleach affected his infection? Ie. was there a change at the wound site? Were there any signs of infection on the labs you did get? Were there any adverse affects of the bleach? Why do you think his blood was hypercoagulable?

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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